ATTENTION: The Department of Health Professions cannot guarantee anonymity.
A copy of your complaint and any supporting documentation provided by you may be shared with the subject of the complaint (practitioner or licensee) pursuant to the Code of Virginia § 54.1-2400.2 (G).
Using the online complaint form may help preserve your anonymity.

If you wish to submit an anonymous complaint, please ensure you do not include any information on the complaint form or supplemental documents that reveals your identity.

If you wish to use an alternative method for filing a complaint and wish to remain anonymous, do not include any information on the complaint form, envelope, email address, body of email, or supplemental documents that reveals your identity.

First Name

Middle Initial

Last Name

Business Name (If Applicable)

Address 1

Address 2

City

State

(Not Specified)

Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Federated States of Micronesia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Marshall Islands

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Northern Mariana Islands

Ohio

Oklahoma

Oregon

Palau

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

U.S. Minor Outlying Islands

Utah

Vermont

Virgin Islands of the U.S.

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Zip Code

Home Phone

Work Phone

Fax Number

Email Address

Relationship to the Practitioner

(Not Specified)

Patient/Client

Patient/Client's Relative/Friend

Co-Worker

Supervisor

Other (Specify)

&nbsp&nbsp

Subject of Report (Practitioner)

NOTE: If you would like to complain about more than one practitioner, you will need to submit a separate complaint form for each individual/entity you would like to complain about.

Title

Dr.

Mr.

Ms.

First Name*

Middle Initial

Last Name*

Gender

Unknown

Unknown

Female

Male

License Type (e.g. M.D., RN, DDS, etc.)

License Number

Business or Facility Name (If Applicable)

Address 1

Address 2

City

State

(Not Specified)

Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Federated States of Micronesia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Marshall Islands

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Northern Mariana Islands

Ohio

Oklahoma

Oregon

Palau

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

U.S. Minor Outlying Islands

Utah

Vermont

Virgin Islands of the U.S.

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Zip Code

Home Phone

Work Phone

Fax Number

Email Address

Note: Asterisk (*) signifies a required field. Put N/A if the field does not apply or if you are unable to answer any required field. If filing on a facility regulated by DHP (e.g. pharmacy, veterinary establishment, funeral establishment) answer N/A for first and last name and type the name of the facility into the Business Name field.

Note: At least some of this information must be filled in or we cannot verify your complaint.

Details of Report

* What did the practitioner do or fail to do? Include specific details: Who, What, Where, When.&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp Characters Remaining: 4000Should the space below be insufficient to hold the details of your complaint, there will be an opportunity to add attachments on a later page.Note: Asterisk (*) signifies a required field.

The Patient/Client sustained injury or harm as a result of the licensee's Actions.